Download Blepharitis - Vision 2020 UK

Version 8
Condition
Aetiology
Predisposing
factors
Symptoms
Blepharitis (Inflammation of the
lid margins)
Anterior blepharitis (also known
as Anterior Lid Margin Disease,
ALMD)
- bacterial (usually
staphylococcal)
caused by (1)
direct infection, (2)
reaction to staphylococcal
exotoxin or (3)
allergic response to
staphylococcal antigen
- seborrhoeic (disorder of
the glands of Zeis and
Moll)
Posterior blepharitis (also
known as Posterior Lid Margin
Disease, PLMD)
- Meibomian gland
dysfunction
not due to direct
infection
bacterial lipases
break down Meibomian
lipids
Meibomian
secretion becomes
abnormal both chemically
and physically
Mixed anterior and posterior
blepharitis
All of these conditions are
typically bilateral and chronic or
relapsing
Dry eye syndrome (KCS) present
in:
- 50% of people with
staphylococcal blepharitis
- 25-40% of people with
seborrhoeic blepharitis
Seborrheoic blepharitis
- seborrhoeic dermatitis (for
example, of the scalp)
Posterior blepharitis
- acne rosacea
Anterior blepharitis
(May be asymptomatic)
Ocular discomfort, soreness,
burning, itching
Mild photophobia
Symptoms of dry eye including
blurred vision and contact lens
intolerance
Posterior blepharitis
(May be asymptomatic)
Ocular discomfort, soreness,
burning, stinging
Referee
Evidence needed?
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-
stinging caused by tear
film breakdown
Blurred vision (variable) caused
by abnormal tear film lipid
Signs
Anterior blepharitis
(staphylococcal)
Lid margin hyperaemia
Lid margin swelling
Crusting of anterior lid margin
(scales around bases of lashes ‘collarettes’)
Misdirection of lashes
Loss of lashes (madarosis)
Recurrent styes and (rarely)
chalazia
Conjunctival hyperaemia
Aqueous tear deficiency
Secondary signs include:
punctate epithelial erosion over
lower third of cornea; marginal
keratitis; phlyctenulosis;
neovascularisation and pannus;
mild papillary conjunctivitis
Anterior blepharitis
(seborrhoeic)
Lid margin hyperaemia
Oily or greasy deposits on lid
margins
Conjunctival hyperaemia
Aqueous tear deficiency
Posterior blepharitis
Thick and/or opaque secretion at
Meibomian gland orifices
Foam in the lower tear film
meniscus (due to excess tear film
lipid)
Plugging of duct orifices with
abnormal lipid leading to dilatation
of glands and formation of
microliths and chalazia
Conjunctival hyperaemia
Aqueous tear deficiency, unstable
pre-corneal tear film
Secondary signs include:
punctate epithelial erosion over
lower third of cornea; marginal
keratitis; scarring;
neovascularisation and pannus;
mild papillary conjunctivitis
Differential
Allergy (e.g. to eye drops, eye
diagnosis
drop preservatives or cosmetics),
dacryocystitis, stye, chalazion,
parasites (e.g. Phthyris pubis
infestation), preseptal cellulitis,
herpes (simplex or zoster)
Management by Optometrist
NonLid hygiene is first line of
pharmacological
management regardless of type of
blepharitis. This wipes away
This reads OK.
Evidence is needed re: effective
cleaning agents.
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bacteria and deposits from lid
margins and mechanically
expresses the lid glands
- using diluted baby
shampoo, sodium
bicarbonate solution or Lid
Care® solution with a
swab or cotton bud,
patient cleans lid margins
(but not beyond the mucocutaneous junction)
- carry out twice daily at
first; reduce to once daily
as condition improves
- use firm pressure with
swab or cotton bud so as
to express glands
Warm compresses to loosen
collarettes and crusts
Advise the avoidance of
cosmetics, especially eye liner
and mascara
Treat seborrhoeic dermatitis and
dandruff, which are disorders
associated with skin yeasts, with
medicated shampoos containing
e.g. selenium sulphide or
ketoconazole
Advise patient to return/seek
further help if symptoms persist
Complete eradication of the
blepharitis may not be possible,
but long-term compliance with
these measures should reduce
symptoms and minimise the
number and severity of relapses
While there are many anecdotal
papers recommending various
solutions for lid hygiene including
Johnson's baby shampoo, sodium
bicarbonate, I-Scrub, OCuSoft,
[1,2,3,4,5,6] the evidence base for the
various cleaning agents is limited. In
terms of experimental evidence, one
study was found on rabbits which
shows that baby shampoo causes
more conjunctival oedema and
hyereamia than I-Scrub (a
commercial cleaning agent.[7] These
authors then tested the effect of I –
Scrub on patients without a control
group. They found15/20 patients
report that I-Scrub reduced itching
and discomfort. [7]
Another study was located which had
sampled 26 patients with blepharitis
and compared the effect of OCuSoft
(a commercial cleaning agent) to
Neutrogena soap over four months.
Slit lamp examinations at six weeks
and four months showed that 17/25
preferred the OCuSoft.[8] The
authors then compared the OCuSoft
with Johnson’s baby shampoo in a
sub-group of 10 patients and found
that 5/10 and 4/10 preferred the
OCuSoft and baby shampoo
respectively.[8]
Finally a more recent prospective
study compared clinical and biological
tolerance and efficiency between a
group of blepharitis sufferers who
applied isotonic 0.1% zinc sulfate
solution and another group which
used natural selenium-rich thermal
water (ie. La Roche-Posay thermal
water).[9] Unfortunately, they do not
state how frequently the solutions
were applied. However, they report
that both groups had no signs
functional irritation signs, no potential
conjunctive and cornea irritancy,
lower lacrimal pH acidity rate, and
preservation of the lacrimal lipid layer.
In addition, the solutions were
concluded to have corrected the
pathogenic cycle efficiently because
there was palpebral edge lipid
reduction, meibonius glands orifice
diameter reduction, and preservation
of the saprophyte conjunctival flora.
Overall as Chan and Franics (2004)
argue, there is still a need for a
prospective randomised controlled to
find the most effective cleaning
agent.[4]
Version 8
1. Leibowitz HM, Capino D.
Treatment of chronic
blepharitis Archives of
Ophthalmology 1988;106:720
2. Smith RE, Flowers CW,
Chronic blepharitis: a review.
the CLAO journal. 1995;21(3)
200-207
3. Shaw M. (2002) Recognising
and managing blepharitis
Ophthalmic Nursing:
International Journal of
Ophthalmic Nursing
2002;6(2):24-28
4. Chan DG, Francis IC.
Comment on ‘Glaucoma from
topical corticosteroids to the
eyelids Clinical and
Experimental Ophthalmology
2004; 32(6) 656-657.
5. Pettinger D. Sodium
bicarbonate in the treatment
of blepharitis. Clinical and
Experimental Ophthalmology
2005; 33: 448.
6. Figueiro E, Chan DG, Francis
IC. Response to ‘Sodium
Bicarbonate in the treatment
of blepharitis’ eyelids Clinical
and Experimental
Ophthalmology 2005; 33(4)
448-9
7. Polack FM, Goodman DF
Experience with a new
deterrgent lid scrub in the
management of chronic
blepharitis Archives of
Ophthalmology
1988;106:219-720
8. Key JE A comparative study
of eyelid cleaning regimens in
hronic blepharitis the CLAO
journal 1996; 22(3): 209-212
9. Sore G, Rougier A, Richard
A, Pericoi M. Ocular tolerance
and efficiency of two solutions
applied to non-infectioua
blepharitis European Journal
of Dermatology 2002;
4(12)LXII-IV
Pharmacological
If infection is present, and after
deposit removal:
oc chloramphenicol bd; place
in eyes or rub into lid
margin with fingertip
or
oc polymyxin/bacitracin bd
(apply as above)
or
gutt fusidic acid bd to eyes
Consider prescribing a systemic
tetracycline, such as
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oxytetracycline, doxycycline or
minocyclin. Such treatment will
need to be continued for several
weeks or months and the dosage
may need to be varied from time
to time. These drugs are
contraindicated in pregnancy,
lactation and in children under 12
years
Management of aqueous tear
deficiency, if also present: refer to
Guideline on tear deficiency
If marginal keratitis is present, refer
to Guideline on marginal keratitis
Management
category
B2: Alleviation/palliation:
normally no referral.
B1: initial management
followed by routine referral if
adequate trial (six weeks of
therapy) does not produce
sufficient response. Consider
co-management with GP or
Ophthalmologist
Management by Ophthalmologist
Oral drugs of the tetracycline
family (contraindicated in
pregnancy, lactation & children
under 12 years; various adverse
effects have been reported), or
other systemic antibiotics